Too Much of a Good Thing

TYLER ANSTETT
Assistant Professor, University of Colorado School of Medicine

Optimal utilization of blood products requires a balance between clinical benefit and unnecessary costs and risks associated with transfusions. Excess packed red blood cell (pRBC) transfusions are associated with harm to patients and additional costs to patients and health systems. The American Association of Blood Banks recommends a restrictive threshold of a pre-transfusion hemoglobin (Hgb) level of less than 7.0g/dL and single unit pRBC transfusions for the vast majority of hospitalized patients. Other institutions have significantly improved pRBC utilization through Electronic Health Record (EHR) focused interventions. In this project, we sought to conduct a needs assessment across the UCHealth system and evaluate the optimal strategy for encouraging prudent transfusions.

We examined the inpatient transfusion practices at five UCHealth hospitals across three regions: North, South, and Denver Metro between 2/1/2019 – 1/31/2020.

Data was acquired from the Clarity tabulation of the EPIC EHR. We included adult patients (> 17 years), who received a blood transfusion during an inpatient encounter. We excluded both perioperative hospital units and outpatient transfusions. We analyzed the data by the pretransfusion hemoglobin value as well as the number of pRBCs transfused for each Hgb value. We also examined the blood transfusion ordering interfaces at each hospital to evaluate for trends.

18,055 units of pRBCs were transfused during 13,804 transfusion administrations across all regions during the study period. 7,015 (51%) of transfusions were for pre-Hgb ≥ 7.0, and of all transfused units 3,471 (25%) of transfusions included two or more units of pRBC for pre-Hgb greater than 6.0. There was some heterogeneity across the institutions with transfusions for ≥ 7.0 ranging from 44% to 68%. Analysis of the ordering interface revealed regional differences that did not impact ordering practices, with University Hospital having the least directive interface but the lowest percentage of transfusions for Hgb ≥7.0g/dL at 41%. None of the blood transfusion ordering interfaces include proven strategies for reducing unnecessary transfusions.

As demonstrated by the pre-Hgb level of the transfusions and number of units transfused each time, these data support the need for improvement across the UCHealth system. We are embarking on a clinician level randomized user-centered, design-focused pragmatic factorial trial manipulating the blood transfusion ordering interface to evaluate the most effective method for reducing unnecessary blood transfusions. The trial design will account for the two main interventions (Overutilization of pRBC for pre-Hgb ≥ 7.0 and multiple units per transfusion order with pre-Hgb ≥ 6.0). We currently working with UCHealth leadership for approval of the design.